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Parsimonious RBC
Transfusion: State of the Art
Moises Auron, MD, FAAP, FACPAssistant Professor of Medicine and
Pediatrics
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Disclosure of Financial Relationships
Dr. Auron has no relationships with entities
producing, marketing, re-selling, or
distributing health care goods or services
consumed by, or used on, patients.
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Outline
Anemia Physiology
Current evidence for transfusion medicine
Adverse effects of blood utilization
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It is right to say
The safest transfusion is the one that isavoided
The best transfusion is the one that isavoided
What is the evidence? What is the comparison?
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Physiology
Pre-load
After-load Stroke volume (SV)
Contractility
SV x Heart rate = Cardiac output (CO)
CaO2= SaO2 x 1.34 x Hb + [PaO2 x 0.003]
DO2= CO x CaO2
O2ER = VO2/DO2 (~20-30%)
DO2crit= < 7.3 ml O2/kg/min
Madjdpour C, et al. Crit Care Med 2006; 34[Suppl.]:S102S108.
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Physiology
Acute response to Anemia
Central CO
Regional Redistribution
Microcirculationcapillary recruitment
http://www.frca.co.uk/article.aspx?articleid=100345
Shander A, et al. Brit J Anaesth 2011;107 (S1): i41i59.
http://www.frca.co.uk/article.aspx?articleid=100345http://www.frca.co.uk/article.aspx?articleid=1003457/31/2019 Evidence for Parsimonius RBC Transfusion
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Outline
Anemia Physiology
Current evidence for transfusion medicine
Adverse effects of blood utilization
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Anemia tolerance: what is theideal hemoglobin level?
Cardiovascular effect
- Coronary artery disease
- Valvular disease
- Elderly patient
CNS effects
Effects on splachnic and renalperfusion
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Preoperatory Anemia andCardiovascular Disease
Carson JL. Lancet 1996; 348: 105560.
Retrospective (N = 1958)
Jehovah's witnesses > 18a
Mortality 1.3% (Hb > 12)
Mortality 33.3% (Hb < 6)
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Circulation. 2007;116: 471-479.http://www.euroscore.org
N = 5065
4804 were not transfusedbefore surgery
Hb < 11 increase in post-op adverse effects (renal,
CNS (P=0.001))
Specially in patients withEUROSCORE > 4
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Journal of Cardiac Failure. 2004:10(6)467-72.
N = 1,136,201
1996-1997
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N = 227 425 patients (69 229 preoperatory anemia)
Postoperative mortality (30 days) (OR 1.42, 95% CI 1.31-1.54)- Mild Anemia (OR 1.41, 1.30-1.53)
- Moderate-severe Anemia (OR 1.44, 1.29-1.60)
Postoperative morbidity (30 days) (OR 1.35, 1.30-1.40)
- Mild Anemia (OR 1.31, 1.26-1.36)
- Moderate-severe Anemia (1.56, 1.47-1.66)
Lancet 2011; 378: 1396407.
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What is my cut-off Hemoglobinvalue to transfuse?
10/30?
- Based in experience
- Not supported by evidence Indiscriminate use of blood
- USA: 15 million pRBC/year
- Global: 85 million pRBC/year
Carson JL, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Int Med 2012.
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Anesth Analg 1996;82:687-94.
Hb 12.60.2 to 9.9 0.2 g/dl
N = 90 (60 hemodilution)
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Crit Care Med. 2005 Mar;33(3):591-7.
- Hemoglobin 131.3 to 9.31 g/dl
- No left ventricle dysfunction or hemodynamic
instability.
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Anaesthesia, 2004;59:11701177.
Hb 9.1 g/dL Increase C.I, C.O, and pre-load indexes
- Less viscosity increases venous return, pre-load increase stroke voume
- Consider in patients with preserved LV function
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Anaesthesia, 1998;53:20-24.
Increase in C.I and O2 extraction (VO2/DO2)- Independent of baseline rhythm
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Anesthesiology. 2000;92:1646-52.
Immediate memory
Delayed memory
Horizontal addition
Numeric substitution
There is no difference between time ofreaction (speed and precision ofprocessing information) or in immediateand delayed memory between
Hemoglobin of 7 g/dL vs. 14 g/dL.
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Anesthesiology 2002; 96:8717.
N = 31 healthy volunteers (28 y/o +/- 4)Tests: verbal and standard memory; computerized neuropsychologicalBasal hemoglobin 12.7 g/dL hemodilution to 5.7 g/dL
There is no difference in reaction time inpatients with Hemoglobin of 5.7 g/dL whoused supplemental O2 (PaO2 > 350 mm Hgequals to increase Hb ~ 2-3 g/dL reverseeffects of acute anemia
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Renal and splachnic perfusion
Studies in animals (dogs)
Normovolemic hemodilution
- Hct 30- Hb 7 g/dL
Preserve adequate renal perfusion and
blood distribution
Habler O, et al. Eur J Med Res1997;2:419424.
Meier J, et al. Clin Physiol Funct Imaging2005; 25: 158-65.
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18% vs. 23%
NEJM 1999;340(6):409-17.
TRICC StudyN = 838Hb < 9.0 g/dL
Euvolemic
Restrictive Hb < 7 g/dL(N = 418)
Liberal Hb < 10 g/dL
(N = 420)
8.7% vs. 16.1%
5.7% vs. 13%
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TRIPICU Study (non-inferiority)
N = 637 hemodinamically stable children
320 Transfused for Hb < 7.0 g/dL
317 Transfused for Hb < 9.5 g/dL
No significant difference in prognostic markers(death, infections, inpatient stay in ICU).
N Engl J Med 2007;356:1609-19.
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N Engl J Med 2011;365:2453-62.
Patients > 50 y/o
10 g/dL 8 g/dL
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Liberal Hct 30.6%Conservative Hct 27.9%
Am J Cardiol 2011;108:11081111.
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Rao SV, et al. JAMA 2004. 292(13):1555-62.
N = 24112
Acute coronary syndromes
Studies: GUSTOIIb,
PURSUIT, PARAGON B
HR 3.94; (95% CI, 3.26-4.75)
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J Surg Research. 2002; 102:237
244.
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ComplicationBlood
> 14 d (%)
Blood
< 14 d (%)
P
Inpatient
mortality2.8% 1.7% 0.004
Mortality at 1
year11% 7% 0.001
Prolonged
intubation
(>72h)
9.7% 5.6% 0.001
Renal failure 2.7% 1.6% 0.003
Sepsis 4.0% 2.8% 0.01
N Engl J Med 2008;358:1229-39.
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Changes in aging blood
RBC age rapidly in refrigeration 75%viable at 24hs
Decreased ATP and 2,3 DPG
Loss of membrane phospholipids
Progressive structural rigidityechinocytes at 14-21 days
Poor tissuedelivery of O2
Holme S. Transfus Apher Sci 2005;33:5561.
Hovav T, et al. Transfusion 1999; 39(3):277-81.
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Crit Care Med 2006; 34[Suppl.]:S102S108
Physiologic factors that indicate blood transfusion
Hypotension and tachycardia refractory to euvolemia
New ST depression > 0.1 mVNew ST elevation > 0.2 mV
New LV free wall motion abnormality (Echocardiogram)
PVO2 < 25 mmHg
O2ER > 50%
SVO2 < 50%
Decrease VO2 > 10%
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Crit Care Med 2006; 34[Suppl.]:S102S108
Hemoglobin levels that indicate blood transfusion
All patients 7Patients > 80 y/o 7-8
CAD/CHF 8
SaO2 < 90% 8
Catabolic state 7-8
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Transfusion limits: Guidelines
Society Year Hb Limit (g/dL)
ASA 1996 6
BCSH (British Committee of
Hematology Standards) 2001 7
Australian and NZ Society of
Blood Transfusion 2001 7
ESC (European Society of
Cardiology) 2007 8
SCCM/ACCM 2009 7
AABB (American Assoc of
Blood Banking) 2012 7
Anesthesiology. 1996;84:732-47. Murphy MF, et al. Br J Haematol. 2001;113:24-31.
http://www.nhmrc.gov.au/guidelines/publications/cp78 (2001) Bassand JP, et al. Eur Heart J. 2007;28:1598-660.
Napolitano LM, et al. J Trauma. 2009;67:1439-42. Carson JL, et al. Ann Int Med 2012 (online first).
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Transfusion restriction andmortality
Carson JL, et al. Transfus Med Rev. 2002;16(3):187-99.
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Transfusion restrictive strategy
Critical patients consider transfusion if Hb< 7 g/dL
Post-op surgical patients - consider
transfusion if Hb < 8 g/dL or if symptomatic(angina; orthostatic hypotension; tachycardia
refractory to IVF resuscitation, CHF)
Carson JL, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Int Med 2012.
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Outline
Anemia Physiology
Current evidence for transfusion medicine
Adverse effects of blood utilization
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Blood transfusion: Risks
Carson JL, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Int Med 2012.
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Infections: HCV, HBV, HIV, HTLV, XMRV Immunologic reactions:
- Non-hemolytic febrile reaction
- Early and delayed hemolytic reactions
- Anaphylaxis
- Urticaria
TRALI
TACO
TRIM ( infections)
XMRV Chronic fatigue syndrome?
Meiers J. Transfus Med Hemother 2012;39:98103http://www.frca.co.uk/article.aspx?articleid=100902
Blood transfusion: Risks
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